Endovascular treatment for ruptured distal anterior inferior cerebellar artery aneurysm

Treatment and Outcome of Anterior Inferior Cerebellar Artery (AICA) Aneurysms: Helsinki Series of 15 Consecutive Patients

Objective Anterior inferior cerebellar artery (AICA) aneurysms are rare posterior circulation lesions that are challenging to treat. This article presents the treatment and clinical outcome of AICA aneurysms in an unselected cohort of patients.

Methods A retrospective analysis of patient record files, digital subtraction angiography, and computed tomography angiography images of 15 consecutive patients harboring AICA aneurysms treated between 1968 and 2017.

Results Of the 15 AICA aneurysm patients reviewed, 12 (80%) were females. Twenty percent had intracerebral hemorrhage and 40% presented with intraventricular hemorrhage. Eleven out of 15 (73%) patients presented with subarachnoid hemorrhage (SAH); 82% of SAH patients had a good-grade SAH (Hunt and Hess grade 1–3). Eleven patients (73%) were treated surgically, three (20%) were treated conservatively, and one (7%) had coil embolization. In 27% of patients, a subtemporal approach with anterior petrosectomy was performed. A retrosigmoid approach was used in the remaining 73%. In 18% of the patients, a parent vessel occlusion was necessary to occlude the aneurysm. Five out of 11 (47%) of the patients developed postoperative cranial nerve deficits. Twenty-seven percent developed shunt-dependent hydrocephalus. All patients who presented with an unruptured AICA aneurysm had good clinical outcome (modified Rankin scale [mRS] 1–2). In patients with SAH, 82% achieved good clinical outcome and 18% had poor clinical outcome (mRS 3–6) after 1 year.

Conclusion Surgical treatment of AICA aneurysms has a high rate of cranial nerve deficits but most of patients have a good long-term clinical outcome.

Dissecting distal cerebellar artery aneurysms: options beyond a parent vessel sacrifice

Parent vessel occlusion (PVO) is the conventional endovascular treatment (EVT) for dissecting distal cerebellar artery aneurysms (DCAA). The associated ischemic sequelae are often well-tolerated. However, at the outset, the magnitude of this risk is uncertain. Meanwhile, non-PVO endovascular treatments (EVT) are deemed to provide incomplete protection from a rebleed. This study reviews our experience in the management of dissecting DCAA with emphasis on the effectiveness of parent vessel-preserving endovascular strategies as compared to PVO. Our institutional database was reviewed for all the dissecting DCAA aneurysms treated by endovascular means between Nov 2015 and Oct 2018. Their clinical presentations, imaging findings, EVT techniques, and clinical outcomes were retrospectively evaluated. Eighteen dissecting DCAA were identified: 13 in the posterior-inferior cerebellar artery (PICA), 3 in anterior-inferior cerebellar artery (AICA), and 2 in superior cerebellar artery (SCA). Median patient age was 61 years (range 40-86; average 60.7 years) with a 5:1 female predominance. Nine (6 in the PICA and 3 in the AICA) patients were managed by parent vessel-preserving strategies (6 with isolated endosaccular coiling and 3 with telescoping stents) while the remaining 9 (7 in the PICA and 2 in the SCA) were treated by PVO.The frequency of early rebleed was the same (11%) in both the treatment arms. One patient from the PVO arm suffered an extensive cerebellar infarct that mandated decompressive craniectomy and adversely affected her recovery. There were no such complications in patients treated with parent vessel-preserving strategies. No recurrence/rebleed was encountered in the 3 aneurysms secured using telescoping stents. Overall, excellent clinical outcomes (mRS of 0 and 1) were sparsely seen in the patients who had PVO (89 vs 23%). In dissecting DCAA, aforedescribed, parent vessel-preserving strategies are as effective as the more frequently used option of PVO in preventing an early rebleed. However, these are technically challenging, may be feasible in a smaller proportion of patients, and would need meticulous imaging follow-up in the acute period. When successfully implemented, these strategies can deliver excellent clinical outcomes and eliminate the uncertain risk of ischemic complications associated with PVO.

Anterior inferior cerebellar artery aneurysms: Segments and results of surgical and endovascular managements

BACKGROUND

Anterior inferior cerebellar artery (AICA) aneurysms are rare and published clinical experience with these aneurysms is limited.

OBJECTIVE

The objective of this article is to report angiographic characteristics and results associated with premeatal, meatal and postmeatal segments, surgical and endovascular therapies.

METHODS

A literature review was performed through PubMed using "anterior inferior cerebellar artery aneurysm" through January 2016. Clinical data, angiograms, management techniques, and patient outcomes were reviewed for 47 collected cases in 30 previous reports.

RESULTS

Of these aneurysms, 21 (44.7%) were associated with meatal segment, 10 (21.3%) were postmeatal and 16 (34.0%) were premeatal. Patients with meatal aneurysms are more likely to present with subarachnoid hemorrhage and hearing loss and facial palsy (77.8%). Patient outcomes of meatal aneurysms presented with more neuropathies (51.7%) and cerebellar symptoms (14.3%) (p = 0.049). Four cases of meatal aneurysm with preoperative cranial nerve deficits (two VII and two VIII) showed improvement after surgery. Endovascular treatment achieved outcomes similar to surgical treatment (p = 0.327).

CONCLUSIONS

AICA aneurysms have a predilection for meatal segment. Patients with meatal aneurysms are more likely to present with subarachnoid hemorrhage and hearing loss and facial palsy. Patient outcomes of meatal aneurysms presented with more neuropathies and cerebellar symptoms. Endovascular treatment achieved outcomes similar to surgical treatment.

Ruptured distal AICA pseudoaneurysm presenting years after vestibular schwannoma resection and radiation

Distal anterior inferior cerebellar artery (AICA) pseudoaneurysms are very rare lesions. Although cases have been previously reported, only a few have been reported as a result of vestibular schwannoma (VS) radiation, none have been reported as a result of VS resection, and only one has been reported as treated with parent vessel occlusion (PVO) with n-butyl cyanoacrylate (nBCA). We report a case of a 65-year-old man with a history of right-sided VS surgery and radiation who presented years later with a ruptured pseudoaneurysm of the distal right AICA and was treated with endovascular PVO using nBCA. The aneurysm was completely obliterated and the patient had no worsening of symptoms or neurological exam. The case illustrates a very rare complication of VS surgery and radiation as well as an effective treatment for distal AICA aneurysms.

Ruptured distal AICA pseudoaneurysm presenting years after vestibular schwannoma resection and radiation

Distal anterior inferior cerebellar artery (AICA) pseudoaneurysms are very rare lesions. Although cases have been previously reported, only a few have been reported as a result of vestibular schwannoma (VS) radiation, none have been reported as a result of VS resection, and only one has been reported as treated with parent vessel occlusion (PVO) with n-butyl cyanoacrylate (nBCA). We report a case of a 65-year-old man with a history of right-sided VS surgery and radiation who presented years later with a ruptured pseudoaneurysm of the distal right AICA and was treated with endovascular PVO using nBCA. The aneurysm was completely obliterated and the patient had no worsening of symptoms or neurological exam. The case illustrates a very rare complication of VS surgery and radiation as well as an effective treatment for distal AICA aneurysms.